Am I off base?

[KristyW]

Ross, Marty, Karlynn & all,

Ok. Here I sit, trying to guess if my husband's ACT manager is doing a good job. As many of you know, my husband threw a blood clot (no known cause) a week ago. He was in the hospital until noon on Wednesday. They had him on a heparin drip the entire time and he was started on warfarin Tuesday evening 7.5mg/day. We went home with a prescription for fragmin $1000 for 7 days...thank you very much.

So here goes...
Tues morning no warfarin in him so assume an INR of 1.0
Tues evening 7.5mg warfarin & heparin drip
Weds afternoon 7.5 mg warfarin & fragmin injection Weds evening
Thurs morning 7.5 mg warfarin (we take our meds in the am.) Fragmin injection Thurs evening
Friday morning 7.5 mg warfarin, INR of 1.9 no change in dosing, continuing fragmin injections (I wanted to stop the injections since his INR came up to almost theraputic in 3 doses. The Friday a.m. dose wouldn't show yet.)
Sat a.m 7.5 mg & evening injection
Sun a.m. 7.5 mg & evening injection
Mon a.m. 7.5 mg, INR of 5.1

Instructions (that I know of) are stop injections (no kidding!) & skip tomorrow's dose (but I don't know what else)

I'm thinking that since he came up from 1.0 to 5.1 in 7 doses that we should probably drop to 5mg and see from there. Since he's just starting I know that the charts don't necessarily apply.

So here's my plan. Skip tomorrow's dose, 5.0 on Weds (he has another INR test then). And then find out what the clinic says then. This clinic has an ACT manager there only on M-W-F, I bet that they'll want to test him again on Friday.

Am I close?

 

[Lisa in Katy]

What was his dose before? Shouldn't he go back to that?

I'm editing this because I started thinking...Does your husband have a mechanical valve, or do you, or do both of you? If he was on Warfarin previously, he should go back to the dose those was working to keep his INRs steady. If not, it seems that it would depend on his recommended range. Usually people who take Warfarin because of a previous clot have a lower range than mechanical valvers, so 5 mg seems high to me.

 

[KristyW]

What was his dose before? Shouldn't he go back to that?

Lisa,

We're just starting. Trying to get that base dose set.

 

[Bina]

I'm thinking that most hospitals start us off at 5mg to avoid that up swing happening.

 

[Karlynn]

I was wondering as well, why they put him on 7.5 right away. I agree with Bina, 5 is the usual starting dose.

I agree with you too. Suggest that you give 5 a try and see what happens.

 

[KristyW]

I was wondering as well, why they put him on 7.5 right away. I agree with Bina, 5 is the usual starting dose.

My guess is that they saw a 6'4", 270lb man and decided..."He'll need a bigger dose." Ugh!

 

[Ross]

My guess is that they saw a 6'4", 270lb man and decided..."He'll need a bigger dose." Ugh!

Kristy cut him back to 5mg a day and see where he's at in a week. He may end up like me going 5mg 4 days a week and 7.5 3 days a week.

 

[KristyW]

Thanks all.

I'm cutting him back to 5! You know Ross...his INR came up REAL fast. I'm wondering if maybe he'll be a 5-a-day just like me

 

[KristyW]

What was his dose before? Shouldn't he go back to that?

I'm editing this because I started thinking...Does your husband have a mechanical valve, or do you, or do both of you? If he was on Warfarin previously, he should go back to the dose those was working to keep his INRs steady. If not, it seems that it would depend on his recommended range. Usually people who take Warfarin because of a previous clot have a lower range than mechanical valvers, so 5 mg seems high to me.

Hey Lisa

My husband isn't a valve patient at all (I do have a mechanical aortic though). Like I said, he threw a clot a week ago on Monday without any known reason. The docs want his INR 2.0-3.0 which is fine. Of course some idiot said that they want it at 2.5...like that's going to happen. LOL

 

[Blanche]

The family that tests together does their best together

The family that tests together does their best together

Kristy:

We are a two Coumadin taking family. Al has the replaced valve and I have A-fib. It's been easy going for both of us...especially since we found VR.com.

We have the INRatio and test together weekly or bi-weekly.

This is certainly not something that we both wanted, but what the heck. At least we can be help each other.

Wishing you and yours the very best,

Blanche

 

[KristyW]

Thanks Blanche,

My own INR has been very stable for the last couple of years. And really I've been on it 8 years and have had only about 2 instances where it shot up unexpectedly, and 2 other instances where it got a little high. I'm really not worried about me at all, but this starting from scratch is a little mind boggling. I'm a bit upset with my husband's ACT manager because he didn't get written instructions today as to what he's supposed to do. They told him not to take his warfarin, but they didn't tell him how long to hold (we're only holding a day) and then what is he supposed to start back at? So we're just holding tomorrow, and starting back up with 5mg/day from there. Hope to figure it out soon.

 

[ALCapshaw2]

Kristy -

Do you have a copy of AL Lodwick's Dosing Guide?

There is a chart for an INR of 3.6 to 5.0 (desired INR of 2.0 to 3.) which says Hold ONE Dose (optional), decrease weekly dose by 15% (which would put him at 6 mg/day)
Recheck in 2 to 4 weeks.

Since he is just starting and you don't have a good baseline, I would recheck in 1 week.

There is another algorithm for INR >5.0
(which he barely is) which states to hold Warfarin,
recheck in 24 hours (for high dose takers),
restart at 15-20% LESS than previously which still puts him back at 6 mg (based on his 7.5 mg dosing which we known is a WAG = wild a.. guess)

Either way, it sounds like a one day hold
and either 5 mg or 6 mg *should* get him 'closer',
then 'fine tune' to his desired range.

You could also check the AAFP Guidelines.
Ross has posted a link to their charts several times (somewhere).

Disclaimer: I am not a Medical Professional and this should not be construed to be Medical Advice.

 

[KristyW]

Thanks Al,

You all have been a great help. I'm glad I'm not off-base. I don't have Al's dosing guide as my ACT manager is pretty good, and she listens when I say "I won't hold a dose for anything under 4.5! LOL"

 

[ALCapshaw2]

Thanks Al,

SNIP ... I don't have Al's dosing guide as my ACT manager is pretty good, and she listens when I say "I won't hold a dose for anything under 4.5! LOL"

At $5, AL Lodwick's Dosing Guide is a GREAT INVESTMENT in Peace of Mind for ANY anticoagulation patient, 'even if' you have a Great Anti-Coagulation Manager (especially on weekends or at 3 a.m.

'AL Capshaw'

 

[Ross]

Thanks all.

I'm cutting him back to 5! You know Ross...his INR came up REAL fast. I'm wondering if maybe he'll be a 5-a-day just like me

He might well be and perhaps need less then 5! Size doesn't matter, as you well know. Depends on what Mr. Liver does with the metabolization.

Personally for me, if my INR is 5 or over, I withhold two doses and resume schedule. Obvisously his dose needs tweaked down a bit.

If my INR is 4.5 or lower, I withold one dose, half the next and resume. Most people here will disagree with that, but that's what works for me.

 

[KristyW]

Grrrr

Grrrr

Grrrr.

Ok, hubby went today to have INR check. Remember he was at 5.4 on Monday, we skipped Tuesday's dose at took 5 instead of 7.5 this morning. His appointment was at 1:30 and his INR was 3.8. NOW GET THIS, the Dr. told him to restart his warfarin at 7.5 and retest on Friday! Why would they do this? It's obvious that he's still "out of range" from the seven 7.5mg doses previously taken and with a one day hold! I'm completely flummoxed why they would do this.

The only thing that comes to mind is that they're looking at a dosing chart of some kind and seeing "for an INR over 5.0, hold 1 or 2 doses and resume and previous dose" Well, that's ok for someone who has found their "baseline" dose, but not for someone who's not been regulated yet! Sheesh!

We're going to take 5 mg per day. Test on Friday (too soon in my opinion, but what can I say?), and tell them (write them) my reasoning for the dose. With my reasoning being, he overshot his target INR by 2+points on the 7.5 mg dose in less than a week. So obviously that isn't the right dose. He was fairly active from last Thursday on, so activity isn't going to bring it down. It seems we should start at 5mg and dose up if we need to.

Thoughts?

 

[ALCapshaw2]

Grrrr.

Ok, hubby went today to have INR check. Remember he was at 5.4 on Monday, we skipped Tuesday's dose at took 5 instead of 7.5 this morning. His appointment was at 1:30 and his INR was 3.8. NOW GET THIS, the Dr. told him to restart his warfarin at 7.5 and retest on Friday! Why would they do this? It's obvious that he's still "out of range" from the seven 7.5mg doses previously taken and with a one day hold! I'm completely flummoxed why they would do this.

The only thing that comes to mind is that they're looking at a dosing chart of some kind and seeing "for an INR over 5.0, hold 1 or 2 doses and resume and previous dose" Well, that's ok for someone who has found their "baseline" dose, but not for someone who's not been regulated yet! Sheesh!

We're going to take 5 mg per day. Test on Friday (too soon in my opinion, but what can I say?), and tell them (write them) my reasoning for the dose. With my reasoning being, he overshot his target INR by 2+points on the 7.5 mg dose in less than a week. So obviously that isn't the right dose. He was fairly active from last Thursday on, so activity isn't going to bring it down. It seems we should start at 5mg and dose up if we need to.

Thoughts?

Kristy - YOUR plan sounds a Whole Lot more Reasonable to me than the one his Cardio proposed.

No wonder Mal-practice Insurers* advise Doctors to let Real Coumadin Clinics manage their patients rather than for the Doctor to take on that task!

*(recollection of a post from long ago)

'AL Capshaw'

 

[Ross]

I'm fully in favor of you doing your own thing because obviously, they don't know what they're doing. This is the exact same reason I went to home testing and self dosing. I just want to know when they're going to stop blaming the drug for bad things and start admitting to not knowing how to dose it properly.

 

[Karlynn]

Yes - go with your plan. Thank God you now what you're doing! Can you imagine if your DH and you were both new to this??? You'd blame the drug for all the problems.

 

[KristyW]

It does make you shake your head.